304313800-8-19-2020-06-CC-KDEI-BSMSA2-20200819134134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313800
Report Date: 08/10/2020
Date Signed: 08/19/2020 01:42:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	PATHAGAMAGE, HETTIGE ARUNI		FACILITY NUMBER:	304313800
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	08/10/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee Pathagamage H Aruni		TIME COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ketki Desai conducted a Virtual pre-licensing inspection (Relocation) today. Licensee Pathagamage, H Aruni, guided analyst on a tour of the new home via Face time. Per Licensee, family members residing in the home are 3 adults only. The licensee is requesting a small family childcare home license. Per licensee, operation hours will be Monday to Friday, 6:00AM to 6:00PM. Licensee states that she will care for children 3 months -6 years of age. All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a two-story home that consists of 3 bedrooms, 2 and a half restroom, living room, kitchen, dining area, backyard and a garage. There is a stairway in the home which has a child safety gate making it inaccessible to children. Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation and heating. The home has a center Air /Heating system, the A/C unit is installed in the backyard with an installed fenced barrier around it. There is a fireplace in the day care area, and it has been covered with complete dry wall and a wooden shelf cabinet is placed in front serving as a safe barrier. Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children. The licensee states (that there are no poisons on the premises). Licensee was advised that any poisons must be locked with a key or combination lock. Based on the Facility Sketch submitted, areas off limits to children and parents are: Second level of the home, three bedrooms, two bathrooms, garage and kitchen are inaccessible to children, Licensee has locked stopper latches installed on the closets and cabinets. Second level of the home is made inaccessible by placing a wooden child safety gate. Kitchen is off limits and a child safety gate has been installed across the dining room making the kitchen area inaccessible to children. Licensee understands that licensing staff may have access to off-limit areas during inspection visit if necessary. Page 1

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: PATHAGAMAGE, HETTIGE ARUNI	FACILITY NUMBER: 304313800
	VISIT DATE: 08/10/2020

NARRATIVE

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Areas Designated for Day care activities: Children shall enter the home through the front entrance, upon entering on the left-hand side there is a shelf with individual storage cubby boxes where the individual items can be stored. The bathroom designated for day care use is in front of the entrance door, which was observed to be safe and free of hazardous items. There is closet and a cabinet under the sink inside the bathroom, both are was made inaccessible by installing a child safety latch and a lock. Bathroom was clean. Next to the bathroom is a closet where additional cots/ first aid supplies and additional items are placed, it was observed to be locked. Living area is open, designated for day care activities, Dining area is turned to an Infant care room, it has cribs, changing table and toys. The two designated rooms were observed to have age appropriate furniture, toys and educational materials for children in care.

OUTDOOR PLAY AREA: Backyard is designated for outdoor play area, it is fenced and has concrete flooring on the side with grassy area in the middle, which is shaded, age appropriate outdoor toys were observed. Fencing is placed around the grassy area, which serves as a barrier to the plants planted.

Per applicant, there are no pets, firearms, weapons or bodies of water on the premises.

The value on the 2A10BC fire extinguisher indicates fully charged, as indicated on service tag observed. Smoke and carbon monoxide detectors were tested and are operable.

There are toys available for children. Cots shall be used during napping time, linens and blankets shall be provided by the parents. Young infants shall use cribs and playpens.

All the items needed for Infant care (Diapers/ Wipes/ Creams/ lotions/ Food/ Formula shall be provided by the parents, the items shall be stored and labelled with name and date.

Licensee states that she will provide snacks for children in care. Food brought from the children’s homes, those containers shall be labeled with child’s name and properly stored or refrigerated.

Licensee has completed the required Health and Safety with Nutrition and Lead Poisoning component Training and Pediatric First Aid and CPR which expires 9/13/2021. There are first aid supplies available.

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SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2020

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: PATHAGAMAGE, HETTIGE ARUNI	FACILITY NUMBER: 304313800
	VISIT DATE: 08/10/2020

NARRATIVE

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The following was discussed with the applicant:

·Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Civil Penalties will be assessed if not in compliance.
·In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR certification and a valid criminal record clearance associated to the facility license.
·Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
·The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.
Fire and safety drills must be performed every six months and documented for review by the Department.
Children and Staff records must be maintained and updated as needed and must be available for review by the Department.

No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.

All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

Licensees shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.

UPDATE: H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles.
The licensee has submitted proof of immunization. Page-3

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2020

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: PATHAGAMAGE, HETTIGE ARUNI	FACILITY NUMBER: 304313800
	VISIT DATE: 08/10/2020

NARRATIVE

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UPDATE: Health and Safety Code 1596.7995: Beginning January 1, 2018, all licensed providers, applicants, directors and employees to complete training as specified on mandated reporter duties. Training is available at: www.mandatedreporterca.com

Infant Care: Licensee states that she will care for infants. LPA advised the Licensee to sleep infants where they can always be directly supervised and advised against sleeping infants in a separate room. The Licensee states the following as a supervision plan for infants: The infants will sleep in the designated infant room where she will be providing supervision and they shall not be left unattended. LPA provided a copy of the Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics. Online copy can be downloaded at: https://www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
LPA reviewed with applicant the following safe sleep best practices:
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold

Incidental Medical Services (IMS):
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

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SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2020

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: PATHAGAMAGE, HETTIGE ARUNI	FACILITY NUMBER: 304313800
	VISIT DATE: 08/10/2020

NARRATIVE

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OTHER INFORMATION AND FORMS PROVIDED: (Posters were emailed to the Licensee)
 Handouts provided for Never Shake a Baby, Sudden Infant Death Syndrome (SIDS) and Safe Sleeping practices
 Capacity Handout for a Small Family Child Care Home and Large Family Child Care Home was provided.

Per applicant, there are no dual licenses at this address. Applicant’s email address was obtained during this inspection. The applicant was advised that email may be public information.

Once licensed, the applicant is required to adhere to the terms and limitations stated on the license. A copy of this report and all other Licensing reports must be made available to the public for 3 years.

The report was read to the Licensee and the Read Receipt shall serve in lieu of Signature.

Exit interview was conducted with Licensee Pathagamage H Aruni via face time who agrees with the above.

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2020

LIC809 (FAS) - (06/04)

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